What is Intussusception?

Intussusception is the proximal (i.e. upper) bowel segment passing into the distal lower bowel segment, in other words, the intestines intertwining. It is mistakenly known as ‘bowel knotting’ among the public.

In fact, in daily life, especially in cases such as gastroenteritis where bowel movements increase, the intestines enter and exit each other. If the bowel segment that enters cannot come back out, then intussusception findings occur. If the findings do not appear, this condition is temporary and ultrasonography may give misleading findings during this period.

 

Who is Invagination Seen in Children?

Invagination is often given as 1-4 cases in every 1000 live births. It is seen twice as much in males. Invagination is the most common cause of intestinal obstruction (bowel blockage) in children between 3 months and 24 months.

What Causes Invagination?

The cause is still not fully known, but in most cases, there is a history of a feverish upper respiratory tract infection before invagination. This suggests that it may be related to swelling in the lymph nodes throughout the body. Blood circulation in the intertwined intestinal segment is disrupted, severe pain begins due to edema and tissue malnutrition. Cramp-like pain that increases with bowel movements repeats itself many times.

What Causes Invagination in Children?

In invagination in children, usually (80-90%) the ileum (last part of the small intestine) enters the colon (large intestine) and is divided into 4 groups according to the formation type.

1. Idiopathic intussusception (Unknown cause): No specific cause can be determined. However, Payer's plaque hypertrophy that occurs after dietary changes or subsequent viral upper respiratory tract infections due to mesenteric lymphadenopathy and rotavirus gastroenteritis can be held responsible. Because this group is more common in spring and autumn, seasons when upper respiratory tract infections due to viral infections are common. There is usually a recent history of upper respiratory tract infection in this group.
2. Lead point group with leading pathology: In this intussusception, there is an anatomical lesion that will trigger the proximal bowel segment to enter the distal bowel segment. Meckel's diverticulum plays the triggering role most often. However, causes such as lymphoma, appendicitis, polyp, bowel duplications, hemangioma and lymphangioma can also play a role.
3. Chronic and recurrent intussusception: In most cases, there is an anatomical cause that will trigger intussusception. In this picture, the invaginated bowel segments may open spontaneously and then re-invaginate. Here, polyps or tumors containing bowel and/or bowel wall formations should generally be considered.
4. Postoperative (after surgery) invagination: In cases where surgical treatment is performed for abdominal or extra-abdominal reasons, it is an invagination that occurs at the level of the small intestine. It is an invagination that usually occurs within the first week after surgery. It is seen that these patients suddenly start to have clinical complaints such as vomiting and inability to pass gas and stool following a normal surgery period. There are nonspecific intestinal obstruction findings on the standing direct abdominal radiograph. It is more often in the form of jejunojejunal or ileoileal invagination.

What are the Clinical Symptoms of Intussusception in Children?

The most common finding is that a previously healthy and asymptomatic, especially a chubby baby, suddenly and intermittently feels pain and becomes restless and cries.

Vomiting is added to the sudden onset of abdominal pain and restlessness over time, the vomiting initially contains food but later turns bilious (lemon yellow). Then bloody diarrhea begins, the stool becomes the color of ‘strawberry jelly’ as it is classically called. The cramp-like pain that increases with bowel movements repeats itself many times. During these cramps, the baby pulls his feet towards his belly and cries excessively. Then he has a period of silence and sleep in between.

 

Strawberry jelly colored poop

How is Intussusception Diagnosed in Children?

First of all, the disease must be considered for diagnosis. Then, a very good history must be taken and a complete systemic physical examination is performed. The diagnosis is confirmed with laboratory examinations to be performed.

In the history; There is a recent or ongoing upper respiratory tract infection. Or, especially if there is an underlying pathology such as lymphoma, there are clinical findings related to it and especially weight loss and recurrent abdominal pain. In addition, there are the clinical findings described above.

In systemic physical examination, fever, clinical findings due to fluid loss, upper respiratory tract infection findings, bloody stool in the diaper, bilious vomiting, abdominal tenderness and a palpable mass in the abdomen are found.

Routine laboratory tests can be helpful in diagnosis. A leukocyte value of more than 20,000/mm3 can be interpreted in favor of intestinal necrosis. In addition, the Hb (hemoglobin) value may decrease due to bleeding.

Direct abdominal X-rays usually show dilated bowel loops. In the advanced stages of the disease, air-fluid levels, which are signs of intestinal obstruction, occur. If the disease is not treated in time and intestinal perforation develops, free air under the diaphragm may be observed.

 

Barium colonography can be performed for both diagnostic and therapeutic purposes. The crescent shape formed by the barium advancing to the obstruction region and surrounding the ileum in the colon is pathognomonic for intussusception. It is essential that this examination and treatment be performed in a hospital with surgical intervention facilities.

 

Abdominal computed tomography may be useful in cases with diagnostic difficulties. It should be performed especially in patients with suspected lead points (such as lymphoma, duplication, etc.).

How is Intussusception Treatment Performed in Children?

Fluid and Electrolyte Treatment: First, fluid electrolyte and, if necessary, blood treatment is applied due to vomiting and bloody diarrhea. For this, a vascular access is opened, a nasogastric tube is inserted through the nose and a urinary catheter is inserted to monitor urine output.

Then, treatment is applied for intussusception, which can be done in two ways.

1- Enema treatment (Non-Operative): In cases diagnosed early, an enema is administered through the anus. This is also applied in different ways, depending on the facilities of the person performing the procedure and the hospital where it is performed. Air or barium is administered with an enema, which can allow the intussusception area to heal on its own. It is performed with X-ray guidance and the improvement is observed here. This procedure can also be performed under ultrasonography. General anesthesia is not required for this procedure, but this procedure is performed under hospital conditions and, if necessary, in hospitals where surgery is possible.

2- Surgical treatment: An intervention is required to the intussusception area with an open surgical method. In some cases, manual correction of the intussusception area is sufficient, while in others, the area needs to be cut out and stitched end to end (This is completely related to the patient's condition at that moment)

Are There Any Complications of Enema Treatment?

As stated above, this procedure should be performed in hospitals where surgery will also be performed when necessary, and the patient should be prepared as if they were going to have surgery.

There are two serious complications of this procedure.

• Failure of the procedure
• Intestinal perforation

In both cases, open surgery is required. This procedure should be performed in cases where an early diagnosis is made and no underlying lead point is considered.

What is Done Before Intussusception Surgery in Children?

First of all, a good history should be taken and a general physical examination should be performed. Then, the family (mother and father) should be well informed about the process; before the surgery, during the surgery and after. If the child is older, the child is also included in this. A number of tests are performed, these tests are not general and are determined according to the patient. And the patient is also seen by the anesthesiologist, the family and the child are informed about the anesthesia process to be experienced.

What is the Recovery Process Like After Intussusception Surgery in Children?

After the surgery, the patient cannot be fed orally until the intestines start working, so liquid antibiotics and painkiller treatments continue through the vein. After gas and stool are released, oral feeding is started. First, liquid foods are fed, then solid foods. After the abdominal findings are completely resolved, the patient is sent home. This usually takes 3-6 days. The patient can take a bath 3 days after the surgery. If there is pain, redness, swelling or discharge in the surgery area, you should consult a doctor again.

If the intestinal obstruction is opened by giving air or barium, feeding is started after the first gas and stool, your child can be discharged after 12-24 hours.

Is a 2nd Surgery Necessary for Intussusception Surgeries in Children?

It may be necessary in patients with recurrence in rare cases.

What are the Risks of Intussusception Surgeries in Children?

Since the patient will receive general anesthesia during the surgery, there may be anesthesia risks, and the relatives of the patient are informed about this by the anesthesiologist before the surgery.

There may also be some surgical complications (wound site infection, bleeding, recurrence of intussusception, etc.).

*** The information provided here and the content of the website are arranged for the purpose of informing the visitors, especially the families. No information should be considered as advice by the visitors and should lead to any decision or action. The patient should definitely be examined by a pediatric surgeon on the subject, consulted with him/her and made a decision by consulting his/her personal information.